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Inherited Bleeding Disorders in Women with Menorrhagia
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Am Fam Physician. 1998 Jul 1;58(1):227-228.
Menorrhagia is a common complaint that may have several causes, but a specific etiology can be identified in fewer than one half of cases. Kadir and colleagues investigated the role of inherited bleeding disorders in women with menorrhagia.
Women who were referred to a London teaching hospital for treatment of heavy regular menstrual periods were screened for inclusion in the study. Exclusion criteria included diagnosed endocrine or bleeding conditions, use of intrauterine devices and use of certain medications, including anticoagulants, non-steroidal anti-inflammatory agents (NSAIDs) and oral contraceptives. Before screening, patients underwent physical examination and pelvic ultrasonography. Patients with physical conditions such as fibroid tumors, polyps and ovarian tumors that could contribute to menorrhagia were also excluded from the study. Menorrhagia was confirmed by use of standardized charting of blood loss. In 150 women, activated partial thromboplastin time, factor VIII activity, von Willebrand-factor antigen and activity, and factor XI were measured.
Inherited bleeding disorders were identified in 26 of the study subjects (17 percent). The most common condition was von Willebrand's disease (15 women with mild disease and three with disease of moderate severity). Factor XI deficiency occurred in four patients, and two women had both von Willebrand's disease and factor XI deficiency. Two women had another bleeding disorder.
Women with bleeding disorders were significantly more likely than other patients with menorrhagia to report heavy periods since menarche but had no greater incidence of previous anemia, blood transfusions or family history of bleeding disorders. Women with bleeding disorders also reported a greater incidence of symptoms such as easy bruising, bleeding after tooth extraction, and postpartum and postoperative bleeding (but not of symptoms such as bleeding from the nose or gums) when compared with the patients who did not have bleeding disorders.
The authors conclude that bleeding disorders, especially von Willebrand's disease, may occur in a greater proportion of women with menorrhagia than was previously believed. The diagnosis should be suspected in women with a normal pelvic examination who have experienced menorrhagia since menarche, particularly if additional reports of excessive bleeding are given. The authors encourage screening for bleeding disorders, especially von Willebrand's disease, before invasive investigations or treatments for menorrhagia are performed.
Kadir RA, et al. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. February 14, 1998;351:485–9.
editor's note: This study emphasizes the importance of considering the “whole patient” in managing a symptom like menorrhagia. The finding of a bleeding disorder in 17 percent of patients in this study may be high as a result of selection of more severe cases for referral to the teaching hospital and the high proportion of Jewish women (known to have a high prevalence of factor XI deficiency) in the referral population. Nevertheless, correct identification of these cases may prevent treatment failures and unnecessary surgery in women with menorrhagia. Apart from menorrhagia, other symptoms of the disorder(s) may be subtle or nonexistent. Von Willebrand's disease actually refers to a group of conditions that usually have mild symptoms. However, since up to 1.3 percent of the population are affected, most practices undoubtedly include several undiagnosed cases.—A.D.W.
Copyright © 1998 by the American Academy of Family Physicians.
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